Improving Work Environment and Retention in a Progressive Care Unit (Part 2

Improving work environment and retention in a progressive care unit (Part 2 of 2)

Suzanne Beels, MSN, RN, AGCNS-BC, CCRN; Susan Blankenship, MS, BSN, RN, PCCN - CVI Surgery & Educational and Organizational Development

*Part 1 of this 2 part series was featured in the Spring 2022 edition of Within REACH

Concerns regarding high turnover rates amongst 7SPCU nurses, a Cardiovascular Progressive Care Unit (PCU), were identified by department leaders. The 7MPCU and 9SPCU employees were combined in December 2019 to form a new CVI surgery PCU. Nurses were challenged with learning skills to care for cardiac, vascular, and thoracic surgery patients: creating a lengthy competency validation list of high-level skills.

In the Spring edition of Within Reach, we discussed how 7SPCU positively impacted staff satisfaction and turnover by developing a floating charge nurse (FCN) role during hours of high patient churn. Part two discusses the impact on patient satisfaction and recommendations.

Purpose and aims

The quality project purpose was to appropriate a weekday FCN to support RN staffing levels on a CVI Surgery PCU. The project aim was to improve Press Ganey overall measure ‘Responsiveness of Staff’ by increasing scored components related to call button and toileting.

Description of population and benefit

7SPCU is a PCU serving post-operative cardiac, thoracic, and vascular surgery patients. The benefits of establishing a weekday FCN were to develop and maintain frontline clinical expertise and provide throughput support.

Methods and procedures

The FCN role was developed to validate and support a diverse set of competencies and ensure optimal and efficient post-operative care through discharge. The FCN did not carry a standard patient assignment but was available to fill any gaps in care. Typical tasks included managing throughput for seamless transitions in care, accepting and admitting new patients, and providing guidance during critical or crises situations. Direct care made up nearly half of the FCN’s work hours.

The FCN was not a protected role meaning it was often eliminated to use the FCN in standard patient care assignments on 7SPCU as well as across the facility. The 7SPCU RNs elected to work over matrix at a 5:1 patient ratio to maintain an FCN. However, when staffing needs were not met, the FCN was utilized for patient assignments on other units. Out of the 370-day pilot, the FCN was able to perform the role for only 140 days, yet the overall impact was positive.

Assessment and outcome measures and data collection

Press Ganey was used to evaluate patient perception. One set of questions that engaged patients to consider their likelihood to recommend were components of the ‘responsiveness of staff’ score. The questions bedside nurses were most able to influence on a shift-by-shift basis were responsiveness to call bell and timely assistance with toileting. Staff made these two measures a priority.

Findings

Press Ganey scores reflected an overall improvement in patient satisfaction for likelihood to recommend and responsiveness of staff. Call Button Question: I received call button help as soon as I wanted it. The pre-project score was 52.5% of patients received call button help as soon as they wanted it. The post-project score was 76.09%.

Toileting Question: I received toileting help as soon as I wanted it. The overall pre-project score was 65.6% of patients received toileting help as soon as they wanted it. The post-project score was 75.61%. Since project completion and elimination of the FCN role, a downward trend has been noted in both scores.

Additional incidental outcomes that could not be directly associated with the pilot project but occurred simultaneously included: 1. a decrease in CVI PACU (post-anesthesia care unit) hold times (improving throughput for post-surgical patients and decreasing OR downtime), 2. improvement in unit morale and social environment, 3. low HAI (Healthcare Associated Infection) rates, 4. increase in completed patient and quality rounds, 5. improvement in PGPE (Press Ganey Patient Experience) overall ‘likelihood to recommend’ score.

Impact and Recommendations

Without increasing FTEs, the FCN role had a positive impact during the pilot period. The sustainability of the FCN role was not possible due to significant global staffing shortages. The role was absorbed back into standard staffing numbers to cover 7SPCU as well as other units. Since the role was not a protected position, it was not allowed to continue once staffing across PCUs reached critical shortages despite the positive impact on employee turnover, engagement, and patient satisfaction.

The recommendation from the study team was to implement a full-time FCN during the hours of highest patient churn for a minimum of twelve hours per day on surgery days. Additional quality monitoring should be done to measure the impact of having an FCN on nightshifts and weekends. The study team recognized the need to do an individualized unit-based analysis for this project to be successful in other areas.

References

American Nurses Association [ANA]. (2015). Optimal nurse staffing to improve quality of care and patient outcomes: Executive summary. Retrieved from https://www.nursingworld.org/~4ae116/globalassets/ practiceandpolicy/advocacy/ana_ optimal-nurse-staffing_white-paper-es_2015sep.pdf

Elsevier. (2017). Orientation and Retention. Retrieved from https://www.elsevier.com/clinical- solutions/ nurses/orientation-and-retention

Lampo, D. (2019). American Association of Critical Care Nurses [AACN]: Staffing in acute and critical care. Retrieved from AACN https://www.aacn.org/clinical-resources/staffing#

Ulrich, B., Barden, C., Cassidy, L. & Var-Davis, N. (2019). Critical care nurse work environments 2018: Findings and implications. Critical Care Nurse, 39(2), 67-84. Retrieved from http:// aacnjournals.org’ccnonline/article-pdf/39/2/67/116850/67

Waydhas, C., Herting, E., Kluge, S., Markewitz, A., Marx, G., Muhl, E., Nicolai, T., Notz, K., Parvu, V., Quintel, M., Rickels, E., Schneider, D., Steinmeyer-Bauer, K., Sybrecht, G., & Welte, T. (2018). Intermediate care units: Recommendations on facilities and structure. Med Klin Intensivmed/Notfmed, 113, 33-44. doi: https://doi.org/10.1007/s00063-017-0369-7